Comparative Effectiveness

2010

As a result of participating in the Medicaid Medical Directors' Learning Network—an AHRQ Knowledge Transfer project—the Oregon Department of Human Services (DHS) used two AHRQ Effective Health Care Program products to refine State Medicaid policy. Officials in the Oregon DHS Division of Medical Assistance Programs used AHRQ's Evidence Report/Technology Assessment, Integration of Mental Health/Substance Abuse and Primary Care, and the Comparative Effectiveness Review, Efficacy and Comparative Effectiveness of Off-Label Use of Atypical Antipsychotics.

Mental health needs of foster children are a particular concern for the State. Walter Shaffer, MD, Medical Director for Oregon's Division of Medical Assistance, reports that 32 percent of foster children in Oregon were prescribed at least one psychotropic medication between 2004 and 2006. Atypical antipsychotic medications are second-generation drugs designed to cause fewer neurological complications than conventional antipsychotics. Some atypical antipsychotics approved to treat schizophrenia and bipolar disorders are being prescribed off-label for young children with behavior problems such as attention-deficit disorder and aggression.

After Shaffer was introduced to the AHRQ review, Efficacy and Comparative Effectiveness of Off-Label Use of Atypical Antipsychotics, at the June 2007 Learning Network workshop, he sought to explore the safety concerns of second-generation antipsychotic prescribing patterns in young children.

Shaffer then led a DHS workgroup on psychotropic medications for foster children. The workgroup's review was presented to the Oregon Drug Use Review Board, the body that sets Medicaid drug use policy. The Board used AHRQ's Comparative Effectiveness Review findings as background material to develop prescribing guidelines for atypical antipsychotic use in children. Subsequently, a bill was approved by the Oregon legislature in 2009 authorizing annual reviews according to these prescribing guidelines.

Providing mental health services as part of primary care is also a concern for the State. Shaffer found the Evidence Report, Integration of Mental Health/Substance Abuse and Primary Care, to be helpful as he and his colleagues reviewed the integration literature. Although evidence supporting the integration of mental health and primary care is still relatively limited, he appreciates the report's acknowledgment that the best model may not yet have been identified.

State staff reviewed the models discussed in the Evidence Report in looking for ways to promote the integration of mental health, addiction treatment, and primary care. More than 120 local initiatives are actively seeking better outcomes for Oregon Medicaid clients. These initiatives promote integration by developing referral systems to mental health providers or by "co-locating" mental and physical health providers. Oregon DHS coordinates demonstration projects that test locally designed integration services and management structures. Key goals include improving health outcomes, developing regionally designed single points of accountability, and coordinating financing.